SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2024 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.

Summary of Position:

This position provides strategic direction for SummaCare’s development and enhancement of Provider Network Alternative Payment Programs, acting as the SummaCare subject matter expert for Alternative Payment Programs for internal Plan counterparts and members of the Plan’s provider network community.

The Manager, Alternative Payment Programs will negotiate, develop, implement and manage the Plan’s value based reimbursement strategy and identify other Alternative Payment Programs in concert with Finance, Quality and Clinical Business Informatics in accordance with company standards in order to maintain and enhance provider networks and to meet/exceed the company’s accessibility, quality and financial goals.

Provider contract negotiation is an important foundational skill for this position. The degree of judgement, ability to work autonomously, and ability to collaborate and gain consensus across constituencies is more advanced in this position than traditional contracting positions. The majority of time will be spent working in an integrated manner with functions inside of SummaCare in the highly judgmental process of analytically identifying the opportunities where provider groups can successfully improve results.

Formal Education Required:

a) Bachelor Degree or may substitute with 4 years of like experience.

Experience & Training Required:

a) Five (5) years Managed Care Provider Contracting and Reimbursement experience, that has included contracting at an independent level, focusing on innovative or unique payment methodologies, demonstrated financial modeling with the ability to communicate complex concepts at all levels, and demonstrated influencing skills with internal and external stakeholders.

Essential Functions:

1) Negotiates, renegotiates, implements, and manages the ongoing relationship with the Value Based entities in accordance with company standards and strategy with a focus on ensuring compliance with program criteria and success of the program for the Plan and the provider

2) Strategic planning and development of other alternative payment models (e.g. bundled payment, capitation, pay for performance, etc.)

3) Coordinates Joint Operating Committee (JOC) meetings with internal staff and Value Based entities to ensure ongoing communication of program data and the achievement of financial, quality, and clinical objectives through accomplishment of value based initiatives.

4) Maintains knowledge of a variety of contracting payment methodologies and analyzes comparable value based programs from other payors

5) Mentors and assists territory provider relations representatives with planning, implementing, and education of value based program staff and providers.

6) Assists Director with strategic planning, coordination of strategic initiatives and represents department and/or acts as alternate for Director in critical meetings and strategic projects.

7) Monitors and provides ongoing analysis of provider networks to meet or exceed the company’s strategic, accessibility, quality and financial goals.

8) Ensures compliance with all regulatory standards, including all applicable state and federal laws.

9) Other responsibilities as assigned by Director

3. Other Skills, Competencies and Qualifications:

a) Demonstrate positive leadership skills including ability to influence action of others not directly reporting to him/her.

b) Effectively work with a variety of people at all levels, both internally and externally.

c) Apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.

d) Ability to formulate and operationalize creative and unique ideas/methods to address particular issues effectively and efficiently.

e) Demonstrate attention to detail and accurately work with large amounts of contractual data and other legal documents.

f) Skilled in the use of Microsoft Word and Excel.

g) Organize and manage time to accurately complete tasks within designated time frames in fast-paced environment.

h) Maintain current knowledge of industry and related trends.

i) Maintain current knowledge of and comply with regulatory and company policies & procedures.

j) Maintain confidentiality of member and business information.

k) Flexible: ability to adjust work hours to meet business demands.

l) High Degree of analytical skills analyzing data from diverse sources; making recommendations and/or conclusions based on analyses; developing financial, data processing technical reports, procedures, systems that usually affect one department.

m) Ability to communicate complex information verbally and in written form that may include policies and procedures, financial, legal, and/or technical documents, and opinion papers; ability to provide guidance required to implement strategic programs and projects

4. Level of Physical Demands:

b) Sit for prolonged periods of time.

c) Bend, stoop, and stretch.

d) Lift up to 25 pounds.

e) Manual dexterity to operate computer, phone, and standard office machines.

Job Type: Full-time

Pay: $70,012.00 - $105,019.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work Location: Hybrid remote in Akron, OH 44305